Prevention and Treatment of Injuries
Katy High School
Chapter 20, The Knee
Anatomy
MCL, Medial Collateral Ligament
LCL, Lateral Collateral Ligament
PCL, Posterior Cruciate Ligament
ACL, Anterior Cruciate Ligament
Medial Meniscus
Lateral Meniscus
Anatomy
Patella
Tibia
Fibula
Femur
Patellar Tendon
Hamstrings
Quadriceps
Gastrocnemius
Patella
Patella, is the largest sesmoid bone in the human body
Tracking depends on the pull of the quadriceps muscles and the patellar tendon,
the depth of the femoral condyles and the shape of the patella
Medial Meniscus
C-shaped fibrocartilage
Located on the tibia on the medial side
Lateral Meniscus
Is more O-shaped and located on the lateral aspect of the tibia
Both limit lateral movement and serve as a cushion for the knee joint
Meniscus
Cruciate Ligaments
Anterior Cruciate Ligament: comprises three twisted bands: the anteromedial,
intermediate, and posterolateral bands.
Prevents the femur from moving posteriorly during weight bearing. It also
stabilizes the tibia against excessive internal rotation and serves as a secondary
restraint for valgus or varus stress with collateral ligament damage.
Cruciate Ligaments
Posterior Ligament: some of the posterior cruciate ligament is taut throughout the
full range of motion. It acts as a drag during the gliding phase of motion and
resists internal rotation of the tibia. In general, the posterior cruciate ligament
prevents hyperextension of the knee, and femur sliding forward during weight
bearing.
MCL: Medial Collateral Ligament
Attaches above the joint line on the medial epicondyle of the femur and below on
the tibia.
The major purpose is to prevent the knee from valgus and external rotating
forces.
LCL: Lateral Collateral Ligament
The LCL is a round, fibrous cord that is shaped like a pencil. It is attached to the
lateral epicondyle of the femur and to the head to the fibula.
Knee Musculature
Knee flexion is executed by the biceps femoris, semitendinosus,
semimembranosus, gracilis, gastrocmenius, popliteus, and plantaris muscles.
Knee extension is executed by the quadriceps muscle of the thigh, consisting of
three vasti – vastus medialis, vastus lateralis, and vastus intermedius
Knee Musculature
External rotation of the tibia is controlled by the biceps femoris.
Internal rotation is accomplished by the popliteal, semitendinosus,
semimembranosus, sartorius, and gracilis muscles.
The iliotibial band on the lateral side primarily functions as a dynamic lateral
stabilizer.
Bursae
A bursa is a flattened sac or enclosed cleft composed of synovial tissue that is
separated by a thin film of fluid. The function of a bursa is to reduce the friction
between anatomical structures. Bursae are found between muscle and bone,
tendon and bone, tendon and ligament, and so forth. As many as two dozen
bursa have been identified around the knee joint.
Bursae
The Suprapatellar, prepatllar, infrapatellar, pretibial and gastrocmenius bursae
are perhaps the most commonly injured about the knee joint.
Fat Pads
There are several fat pads around the knee. The infrapatellar fat pad is the
largest. It serves as a cushion to the front of the knee and separates the patellar
tendon from the joint capsule.
Assessing the Knee Joint
History
Current Injury
What did you feel, hear, …. Was there a pop or snap?
Did you get hit by another player? Was your foot planted? Did this happen
without being hit?
Exactly where does you knee hurt, and be specific?
Have you hurt this knee before, when, what was the injury?
Assessing the Knee Joint
When did you first notice the condition?
Is there swelling or recurrent swelling?
What activity hurts the most?
Does it ever catch or lock?
Do you fell as if the knee is going to give way, or has it already done so?
Does it hurt to go up and down stairs?
Observation
Does the athlete have a limp, or is it easy to walk?
Cant eh athlete be full weight bearing?
Is the athlete able to perform a half-squat to extension?
Cant the athlete do up and down stairs?
Testing for Knee Joint Instability
Through testing of the knee, one can get a better idea of the stability of the joint
and an informed decision can be made about playing status. Many tests may
point to ligamentous damage, while others will help detect meniscus damage.
Knowing these test and how to perform them takes practice and time to
understand the degrees of damage done to the knee.
Valgus and Varus Stress Tests
These are intended to reveal laxity of the medial and lateral collaterals.
The athlete lie supine with the leg extended.
To test the medial side, the examiner holds the ankle firmly with one hand while
placing the other over the head of the fibula. The examiner then places a force
inward in an attempt to open the side of the knee. The valgus force is applied at
0 degrees and then at 30 degree of flexion.
Valgus and Varus Stress Tests
The valgus examination in full extension tests the MCL, posteromedial capsule,
and the cruciates. The exam at 30 degrees flexion isolates the MCL.
Valgus and Varus Stress Tests
The examiner reverses hand positions and tests the lateral side with a varus
force on the fully extended knee and then with 30 degrees of flexion. With the
knee extended, the LCL and posterolateral capsule are examined. At 30 degrees
of flexion, the LCL is isolated.
Anterior Cruciate Ligament Tests
Drawer Test at 90 degrees: The athlete lies on a table with injured leg flexed.
The examiner stands facing the anterior aspect of the athlete’s leg, with both
hands encircling the upper portion of the leg, immediately below the knee joint.
The fingers of the examiner are positioned in the popliteal space of the injured
leg, with the thumbs on the medial and lateral joint lines. The index fingers of the
examiner are placed on the hamstring tendon to ensure that it is relaxed before
the test is administered.
Anterior Cruciate Ligament Tests
The tibia’s sliding forward from under the femur is considered a positive anterior
drawer sign. If a positive anterior drawer sign occurs, the test should be repeated
with the athlete’s leg rotated internally 30 degrees and externally 15 degrees. A
sliding forward of the tibia when the leg is externally rotated is an indication that
the posteromedial aspect of the joint capsule, the ACL, or possibly MCL could be
torn. Movement when the leg is internally rotated indicates that the ACL and the
posterolateral capsule may be torn.
Anterior Cruciate Ligament Tests
Lachman’s Drawer Test: is considered to be a better test than the drawer test at
90 degrees of flexion. This is especially true immediately after an injury. One
reason for using it immediately after an injury is that it does not force the knee
into the painful 90-degree position but tests it at a more comfortable 20 to 30
degrees. It also reduces the contraction of the hamstring muscles. That
contraction causes a secondary knee-stabilizing force that tends to mask the real
extent of the injury.
Anterior Cruciate Ligament Tests
The Lachman drawer test is administered by positioning the knee in
approximately 30 degrees of flexion. One hand of the examiner stabilizes the leg
by grasping the distal end of the thigh, and the other hand grasps the proximal
aspect of the tibia and attempts to move it anteriorly. A positive Lachman’s test
indicated damage to the ACL
Posterior Cruciate Ligament Tests
Posterior Drawer Test: is performed with the knee flexed at 90 degrees and the
foot in neutral position. Force is exerted in a posterior direction at the proximal
tibial plateau. A positive posterior drawer test indicates damage to the posterior
cruciate ligament.
Posterior Cruciate Ligament Tests
Posterior Sag Test (Godfrey’s Test): With the athlete supine, both knees are
flexed to 9- degrees. Observing laterally on the injured side, the tibia will appear
to sag posteriorly when compared to the opposite extremity if the posterior
cruciate ligament is damaged.
Meniscal Test
McMurray’s Test: is used to determine the presence of a displaceable meniscal
tear within the knee. The athlete is positioned face up on the table with the
injured leg fully flexed. The examiner places one hand on the foot and one hand
over the top of the knee, fingers touching the medial joint line. The ankle hand
scribes a small circle and pulls the leg into extension. As this occurs, the hand on
the knee feels for a clicking response. Medial meniscal tears can be detected
when the lower leg is externally rotated, and internal rotation allows detection of
lateral tears.
Prevention of Knee Injuries
To avoid injuries to the knee, the athlete must be as highly conditioned as
possible, which means total body conditioning that includes strength, flexibility,
cardiovascular and muscle endurance, agility, speed and balance.
THE MUSCLES around the knee MUST be strong and flexible.
Prevention of Knee Injuries
Athletes participating in a particular sport should acquire a strength ratio between
the quadriceps and hamstring muscle groups. Fro example: the hamstring
muscles of football players should have 60 to 70 percent of the strength of the
quadriceps muscles. The gastrocmenius muscle should also be strengthened to
help stabilize the knee. Although maximizing muscle strength may prevent some
injuries, it fails to prevent rotary-type injuries.
Prevention of Knee Injuries
Shoe Type:
Cleat Length
Astro Turf shoes: more grip=more injuries
Sneakers are good for artificial surfaces
Functional and Prophylactic Knee Braces
Functional Knee Braces are used to protect grade 1 and 2 sprains of the ACL
and MCL, and reconstructed ACL knees. Most of them are bilateral knee braces,
meaning there is a hinge on both sides of the brace. These braces have an
important part within the athletic community. They will also give the athlete
confidence while playing.
Functional and Prophylactic Knee Braces
Prophylactic Knee Braces are designed to prevent or reduce the severity of knee
injuries. They are worn on the lateral surface of the knee to protect the medial
collateral ligament.
The Instructors opinion of Prophylactic Knee Braces is that they will never
replace strength, and should be placed on an athlete with caution.
Pre-load ligament –
Time for Physics lesson
Prophylactic Knee Braces
Know what has been presented in the physics lesson.
MCL / LCL Injuries
MCL injuries are usually caused by a lateral to medial blow to the knee. Also
known as a valgus force.
LCL injuries are usually caused by medial to lateral blow to the knee. Also known
as a varus force.
MCL Recognition and Treatment
GRADE I: Recognition
A few ligamentous fibers are torn and stretched
The joint is stable during valgus stress tests
There is little or no joint effusion
There may be some joint stiffness and point tenderness just below the medial
joint line.
Even with minor stiffness, there is almost full passive and active ROM.
MCL Recognition and Treatment
GRADE I: Treatment
Crutches until able to walk without a limp
RICE
Straight leg Raises
Side Leg Raises
Bike
Stair Climber
Functional Progression with pain limiting activity
Return to play with functional bracing or tape
MCL Recognition and Treatment
GRADE II: Recognition
Greater laxity at 30 degrees, as much as 5 to 15 degrees of laxity
Slight or absent of swelling unless the meniscus or ACL has been torn.
Moderate to severe joint tightness with an inability to fully, actively extend the
knee
Definite loss of ROM
Pain in the medial aspect, with general weakness and instability
MCL Recognition and Treatment
GRADE II : Treatment
RICE
Crutches
Knee Immobilizer or Don Joy Playmaker Brace
Modalities to control pain and swelling
Ibuprofen, or NSAIDs
SLR
Side LR
Bike , stair climber, Step Ups (2" then 4")
Functional Progression
Tape and/or Brace to return to activity
MCL Recognition and Treatment
GRADE III: Recognition
Complete loss of medial stability
Immediate severe pain followed by dull ache
Loss of motion because of effusion and hamstring guarding
A valgus stress test that reveals some joint opening in full extension and
significant opening at 30 degrees of flexion.
MCL Recognition and Treatment
GRADE III: Treatment
RICE
Non-operative treatment is preferred
Physician to rule out ACL injury
Immobilization for 2-3 weeks
Increase ROM to 0 to 90 degrees for another 2-3 weeks
Treat as Grade I or Grade II injury but with a longer recovery time.
LCL Recognition and Treatment
Pain and tenderness over the LCL
Swelling and effusion over the LCL
Some joint laxity with varus stress at 30 degrees
If laxity in full extension, check ACL and PCL
Pain with Grade I and II is greatest, and with Grade III initial pain is followed by
dull ache
LCL Recognition and Treatment
Treat similar to MCL sprain. DO NOT DO SIDE LEG RAISES!!
ACL Recognition and Treatment
Will experience a pop followed by immediate disability
Will complain that knee feels like it is "coming apart"
Produce rapid swelling at the joint line
Positive anterior drawer and Lachman's test
ACL Recognition and Treatment
Reduce swelling from initial trauma
RICE
Maintain Quad strength with SLR and Side LR
Keep ROM with Bike
Get knee ready to receive another planned trauma
Teach athlete to ACL protocol that will be used post surgery
ACL Recognition and Treatment
Reconstruction surgery
If left un-repaired, predispose for additional damage
Post surgical care includes protection of knee, increasing ROM, decreasing
Swelling, patellar mobilization, finally strength gain.
One must protect the patellar tendon and also keep scar tissue from being a big
set back.
6 to 8 months rehabilitation time
ACL Recognition and Treatment
Work on QUAD strength with ACL patients, although do not neglect hamstrings.
SLR, Side LR, Total Gym for VMO, Step Ups, Patellar Mobilization, Bike for
ROM, Bike for Endurance, Bike for Strength, Stair Climber, Functional
Progression, Sport Specific Drills
PCL Recognition and Treatment
Athlete will state of a Pop in the back of the knee
Tenderness and relatively little swelling will be evident in the popliteal fossa.
Laxity will be demonstrated in a posterior sag test. The posterior test is fairly
reliable.
PCL Recognition and Treatment
RICE
WORK HAMSTRINGS
If surgical, will take 6 to 8 months to rehabilitate
Meniscal Tears
Effusion developing gradually over 48 to 72 hours
Joint-line pain and loss of motion
Intermittent locking and giving way of the knee
Pain when the athlete squats
THREE Approaches to treatment
Meniscal Tears
Treat Symptomatically
Repair the meniscus, but most tears are not in a position to be repaired
Surgery: It is very important to take out only the torn portion and nothing more.
Meniscal Tears
Maintain Strength
Maintain ROM
Dislocated Patella
The patella dislocates to the lateral side of the knee
Take to a physician immediately
To reduce, hip flexion and knee extension with a little help under the patella
RICE
Could need lateral release could be needed.